Subgroup considerations The evidence that was reviewed did not allow for conclusions about the advantages of treatment support over SAT or vice versa for TB patients; however, in a subgroup analysis of TB patients living with HIV, treatment support showed clear benefit with significantly improved treatment outcomes. It is probable that treatment support may not be beneficial for all patients but that it is likely to have more benefit in certain subgroups of TB patients. Apart from HIV-positive TB patients, other factors or groups of patients that were more or less likely to result in treatment adherence (and therefore require treatment support) were not examined in the scope of the systematic review. Implementation considerations Treatment adherence interventions As treatment support alone is not likely to be sufficient to ensure good TB treatment outcomes, additional interventions for treatment adherence need to be provided. Patient education should be provided to all patients on TB treatment. A package of the other treatment adherence interventions also needs to be offered to patients on the basis of an assessment of individual patients’ needs, providers’ resources and conditions for implementation. With regard to telephone or video-assisted interventions, there may be reluctance to use new technology, making implementation more difficult. There may be privacy concerns regarding the security of telephone data, so encryption and other measures to safeguard privacy will need to be considered. The feasibility of implementing these types of interventions depends on telecommunications infrastructure, telephone availability and connection costs. Multiple organizations have initiated programmes such as these, so TB programmes may find it helpful to collaborate and communicate with other medical service delivery programmes that have already set up such infrastructure. There may be reluctance on the part of implementers (e.g. national or local governments, health partners) to pay for incentives. Implementers may be more willing to pay for material support for smaller subgroups at particularly high risk (e.g. patients with MDR-TB). However, one of the components of the End TB Strategy (121) is to provide “social protection and poverty alleviation” for patients with TB. The strategy specifically calls for measures to “alleviate the burden of income loss and non-medical costs of seeking and staying in care”. Included in the suggested measures are social welfare payments, vouchers and food packages. The benefit of material support found in this review supports these components of the End TB Strategy (121). In order to distribute the material support, a government or nongovernmental organization (NGO) infrastructure would need to be in place, including anti-fraud mechanisms (e.g. reliable unique personal identifiers) and appropriate accounting to ensure that incentives are distributed equitably and to the people who need them most. Countries should choose incentives that are the most appropriate for their situation. Treatment administration Community-based or home-based treatment support has more advantages than health facility-based treatment support, although family members should not be the first or only option for administering treatment support. Treatment support is better provided at home or in the community by trained lay providers or health-care workers. However, there may be challenges in providing community- or home-based treatment support by health-care workers because of the increased number of healthcare workers required and the increased costs for staff time and daily travel to the community or to a patient’s home. Treatment support provided in the community or at home by trained local lay persons is more feasible. A combination of lay provider and health-care worker for provision of community- or home-based treatment support is also an option. Community-based or home-based treatment support is more likely to be acceptable and accessible to patients than other forms of treatment support. Nevertheless, stigma may continue to be a concern with community- or homebased treatment support. Having a health-care worker coming regularly to a patient’s house may be stigmatizing, and the feeling of being “watched over” may be disempowering to patients. Other forms of treatment support (e.g. administered by an emotionally supportive relative or close friend) may be more acceptable but may still be stigmatizing. Given complex family social dynamics, family members may not always be the best people to supervise treatment, so the suitability of such treatment adherence supervisors needs to be carefully analysed in each national or local context. If family members are already providing treatment support, careful identification and training of those persons is required. Additional supervision of local supporters or health-care workers is still needed, as family members cannot be depended on as the only option for care. Patients will continue to need social support, even if family members are providing treatment support. Assessment of potential risk factors for poor adherence must be taken into account by health-care workers at the start of a patient’s treatment in order to decide which treatment administration option should be selected for that patient. Some groups of patients who are less likely to adhere to treatment may gain more benefit from treatment support than others do. Another factor to consider when selecting options for treatment administration is that some patients with inflexible work or family responsibilities may not be able to provide treatment support. Any treatment administration option offered to a patient must also be provided in conjunction with proper medical care, including regular pick-up of TB drugs, consultations with a physician or other health-care workers when necessary, TB treatment that is free of charge, and provision to the patient of essential information on TB treatment.